Breast Flashcards

Question

How do you manage Zuska's disease?

Answer 1

Zuska's disease, AKA recurrent periductal mastitis, is a condition of recurrent retroareolar infections and abscesses. Smoking has been implicated as a risk factor for this condition. Tx: This is managed symptomatically with antibiotics coupled with incision and drainage as needed.

Answer 2

Fungal infections of the breast are rare, and involve blastomycosis or sporotrichosis. Intraoral fungi that are inoculated into the breast tissue by the suckling infant initiate these infections, which present as mammary abscesses in close proximity to the nipple-areola complex. pus mixed with blood may be expressed from sinus tracts. Tx: Antifungal agents can be given for systemic (noncutaneous) infections. Candida albicans affecting the skin of the breast presents as erythematous, scaly lesions of the inframammary or axillary folds. Scrapings show fungal elements (filaments and binding cells). Therapy involves removal of predispoing factors (maceration) and applying topical nystatin.

Answer 3

Hidradenitis suppurativa is a chronic inflammatory condition that originates within the accessory areolar glands of Montgomery (NAC) or within sebaceous glands (axilla). Women with chronic acne are predisposed. May mimic Paget's disease or invasive breast cancer. Often multifocal and contiguous in the axilla. Tx: Antibiotics therapy with incision and drainage of fluctuant areas. Excision of involved areas may be required-- consider flaps and STSG for large areas of skin loss.

Answer 4

Mondor's disease AKA string phlebitis is a variant of thrombophlebitis that involves the superficial veins of the anterior chest wall and abreast. It involves a thrombosed vein presenting as a tender, cord-like structure. Common veins include: Lateral thoracic vein Thoracoepigastric vein Superficial epigastric vein This is a benign and self-limiting disorder (4-6 weeks). But for an uncertain diagnosis or the presence of a mass adjacent to the tender cord, biopsy is indicated. Tx: Anti-inflammatory meds Warm compresses When sx persist/refractory to tx, consider excision of involved vein segment.

Answer 5

Early Reproductive Years 15-25 years old ``` NORMAL Lobular development Stromal development Nipple eversion *Small fibroadenoma ≤1cm ``` DISORDER Fibroadenoma ≤3cm Adolescent hypertrophy Nipple inversion ``` DISEASE Giant fibroadenoma >3cm Multiple fibroadenomas >5 in one breast Gigantomastia Subareolar abscess Mammary duct fistula ```

Answer 6

Later reproductive years 25-40 years old NORMAL Cyclical changes of menstruation Epithelial hyperplasia of pregnancy DISORDER Cyclical mastalgia Painful nodularity >1 week of the menstrual cycle Bloody nipple discharge DISEASE Incapacitating mastalgia

Answer 7

Involution 35-55 years old NORMAL Lobular involution Duct involution (Dilatation, Sclerosis) Epithelial turnover ``` DISORDER Macrocysts Sclerosing lesions Duct ectasia Nipple retraction Epithelial hyperplasia ``` DISEASE Periductal mastitis Epithelial hyperplasia with atypia

Answer 8

NO RISK Nonproliferative lesions Sclerosing adenosis Intraductal papilloma 1.5-2-FOLD RISK Florid hyperplasia 4-FOLD RISK Atypical lobular hyperplasia Atypical ductal hyperplasia 7-FOLD RISK Ductal involvement by cells of atypical ductal hyperplasia 10-FOLD RISK Lobular carcinoma in-situ Ductal carcinoma in-situ

Answer 9

``` NONPROLIFERATIVE 70% of Benign Breast Conditions (No increased risk for cancer) 1) Cysts and apocrine metaplasia 2) Duct ectasia 3) Mild ductal epithelial hyperplasia 4) Calcifications 5) Fibroadenoma and related lesions ```

Answer 10

1) Microcalcifications <0.5mm | 2) Fine, linear calcifications, which may show branching

Answer 11

PROLIFERATIVE WITHOUT ATYPIA 1) Sclerosing adenosis - Childbearing and perimenopausal years - Distorted breast lobules - In the context of multiple microcysts or a palpable mass. 2) Radial scars (≤1cm) and complex sclerosing lesions (>1cm) - Imaging features of a radial scar will dictate the need for either a vacuum-assisted biopsy or surgical excision to exclude the possibility of a carcinoma. 3) Ductal epithelial hyperplasia - Mild: 3 to 4 layers above the basement membrane - Moderate: ≥5 layers - Florid: ≥70% of a minor duct lumen (solid or papillary, 1.5-2 fold risk of CA) 4) Intraductal papillomas - Arise in major ducts, in premenopausal women - <0.5cm but may be as large as 5cm - (+) nipple discharge - attached to wall of involved duct by a stalk - NO increased risk of CA, unless multiple

Answer 12

ADENOMAS Adenomas of the breast are well-circumscribed and composed of benign epithelium with sparse stroma, which is the histologic feature that differentiates them from fibroadenomas. They may be divided into: 1) tubular adenomas (young, nonpregnant women) 2) lactating adenomas (during pregnancy or postpartum) HAMARTOMAS Discrete breast tumors 2-4cm, firm, sharply circumscribed. ADENOLIPOMAS Sharply circumscribed nodules of fatty tissue that contain normal breast lobules and ducts.

Answer 13

ATYPICAL PROLIFERATIVE BREAST LESIONS Have some of the features of carcinoma in situ, but either lack a major defining feature of carcinoma in situ or have the features in less than fully developed form. 1) Atypical ductal hyperplasia (ADH) - appears similar to low-grade DCIS histologically - monotonous round, cuboidal, or polygonal cells enclosed by basement membrane with rare mitoses - ADH: ≤2-3mm - DCIS: >3mm - usually needs excision biopsy for diagnosis - INCREASED RISK for development of breast CA 2) Atypical lobular hyperplasia (ALH) - minimal distension of lobular units with cells similar to those seen in LCIS - small monomorphic cells that distend the terminal ductal lobular unit * LCIS - in LCIS, the acini are full and distended while the overall lobular architecture is maintained). - classic LCIS is not associated with a specific mammographic or palpable abnormality but is an incidental finding noted on breast biopsy. - Pleomorphic LCIS is a variant-- there can be calcifications or other mammographic changes that dictate the need for biopsy. - classic LCIS is not treated with excision as the patient is at risk for developing invasive breast cancer in either breast, and therefore the patient is counseled regarding appropriate risk reduction strategies. - Pleomorphic LCIS can be difficult to distinguish from high-grade DCIS, and there are some proponents who have suggested that patients with pleomorphic LCIS be managed similar to those with DCIS with attention to margins and consideration for RT in the setting of breast conserving treatment. - the use of IHC for e-cadherin can help discriminate between LCIS and DCIS. - -> In lobular neoplasias, such as ALH and LCIS, there is a lack of E-cadherin expression, whereas the majority of ductal lesions will demonstrate E-cadherin activity.

Answer 14

The clinical significance of sclerosing adenosis lies in its imitation of cancer. Excisional biopsy and histologic exam are frequently necessary to exclude the diagnosis of cancer. The diagnostic workup for radial scars and complex sclerosing lesions frequently involves stereotactic biopsy. Usually it is not possible to differentiate these lesions with certainty from cancer by mammographic features, so a larger tissue biopsy is recommended either by way of vacuum-assisted biopsy or an open surgical excisional biopsy. The mammographic appearance of a radial scar or sclerosing adenosis (mass density with spiculated margins) will usually lead to an assessment that the results of a CNB specimen showing benign disease are discordant with radiography findings.

Answer 15

Unlike puerperal abscesses, a subareolar abscess is usually unilocular and often is associated with a single duct system. Ultrasound will accurately delineate its extent. Recurrent abscess with fistula is treated by fistulectomy and primary closure with antibiotic coverage (ie, young women with squamous metaplasia of a single duct). When subareolar sepsis is diffuse rather than localized, or more than one fistula is present, total duct excision is the most expeditious approach (ie, older women with multiple ectatic ducts). Antibiotic therapy is useful for recurrent infection after fistula excision, and a 2-4 weeks course is recommended before total duct excision.

Answer 16

More women request correction of congenital nipple inversion than for nipple inversion secondary to duct ectasia. Although the results are usually satisfactory, women seeking correction for cosmetic reasons should always be made aware of the surgical complications of altered nipple sensation, necrosis, and fibrosis with nipple retraction. Nipple inversion is a result of shortening of the subareolar ducts, hence a complete division of these ducts is necessary for permanent correction of the disorder.

Answer 17

1) Small abscess localized to one segment 2) Recurrence involving the same segment 3) Mild or no nipple inversion 4) Patient unconcerned about nipple inversion 5) Younger patient 6) No discharge from other ducts 7) No prior fistulectomy

Answer 18

1) Large abscess affecting >50% of the areolar circumference 2) Recurrence involving a different segment 3) Marked nipple inversion 4) Patient requests correction of nipple inversion 5) Older patient 6) Purulent discharge from other ducts 7) Recurrence after fistulectomy

Answer 19

HORMONAL 1) Increased exposure to estrogen: - Early menarche - Nulliparity - Late menopause 2) Older age at first live birth 3) Obesity (Major source of estrogen in postmenopausal women is conversion of androstenedione to estrone by adipose tissue; hence obesity is associated with a long term increase in estrogen exposure. NON-HORMONAL 1) Radiation exposure (esp during adolescence, a period of active breast development) 2) Alcohol intake (increases levels of estradiol) 3) Fatty food intake (increases serum estrogen levels)

Answer 20

Factors that decrease the total number of menstrual cycles: 1) Moderate levels of exercise 2) Longer lactation period 3) Terminal differentiation of breast epithelium associated with a full-term pregnancy

Answer 21

1) Age 2) Age at menarche 3) Age at first live birth 4) Number of breast biopsy specimens 5) Any history of atypical hyperplasia 6) Number of first-degree relatives with breast cancer A woman's risk factors are translated into an overall risk score by multiplying her relative risks from several categories. This risk score is then compared to an adjusted population risk of breast cancer to determine a woman's individual or absolute risk. The output is a 5-year risk and lifetime risk of developing breast cancer.

Answer 22

Using data from the Cancer and Steroid Hormone Study (case-control), the Claus risk assessment model is based on assumptions about the prevalence of high-penetrance breast cancer susceptibility genes. This incorporates more information about family history but excludes other risk factors. It provides individual estimates of breast cancer risk according to decade of life based on presence of first and second degree relatives with breast cancer and their age at diagnosis.

Answer 23

The BRCAPRO model is a Mendelian model that calculates the probability that an individual is a carrier of a mutation in one of the breast cancer susceptibility genes based on their family history of breast and ovarian cancer. This is based on age-specific incidence curves for both mutation carriers and noncarriers.

Answer 24

It attempts to utilize both family history information and individual risk information. It uses family history to calculate the probability that an individual carries a mutation in one of the breast cancer susceptibility genes, and then the risk is adjusted based on personal risk factors, including: ``` age at menarche parity age at first live birth age at menopause history of atypical hyperplasia or LCIS height BMI ```

Answer 25

At least 20-25% lifetime risk based on risk assessment tools, considering: 1) Family history of breast CA 2) BRCA mutation carriers 3) Family member with a BRCA mutation who has not been tested 4) Individuals receiving radiation to the chest between 10-30 years old 5) Individuals with a history of Li-Fraumeni syndrome, Cowden syndrome, Bannayan-Riley-Ruvacalba syndrome 6) With a first degree relative with one of these syndromes MRI is an extremely sensitive screening tool that is not limited by the density of the breast tissue as mammography is; however, its specificity is moderate, leading to more false-positive events and the increased need for biopsy.

Answer 26

``` DVT (1.6x more often) Pulmonary emboli (3x more often) Endometrial cancer (2.5x more often) ```

Answer 27

Aromatase inhibitors (AIs) have been shown to be more effective than tamoxifen in reducing the incidence of contralateral breast cancers in postmenopausal women receiving AIs for adjuvant treatment of invasive breast cancer. The American Society of Clinical Oncology recommends tamoxifen for chemoprevention in premenopausal or postmenopausal women and consideration for raloxifene or exemestane in postmenopausal women who are noted to be at increased risk of breast cancer.

Answer 28

Up to 5% of breast cancers are caused by inheritance of germ line mutations such as BRCA1 and BRCA2. These are inherited in an autosomal dominant fashion with varying degrees of penetrance. They both function as tumor suppressor genes, and for each gene, the loss of both alleles is required for the initiation of cancer.

Answer 29

BRCA1 is located on chromosome arm 17q, spans a genomic region of approximately 100 kilobases (kb) of DNA, and contains 22 coding exons for 1863 amino acids. Germline mutations in BRCA1 represent a predisposing genetic factor in as many as: - 45% of hereditary breast cancers - at least 80% of hereditary ovarian cancers. Female mutation carriers have been reported to have up to an 85% lifetime risk (for some families) for developing breast cancer and up to a 40% lifetime risk for developing ovarian cancer. The average lifetime risk is between 60-70%. Approximately 50% of children of carriers inherit the trait. In general, BRCA1-associated breast cancers are invasive ductal carcinomas, are poorly differentiated, are in the majority hormone receptor negative, and have a triple receptor negative (immunohistochemical profile: ER-negative, PR-negative, and HER2-negative) or basal phenotype (based on gene expression profiling). BRCA1-associated breast cancers have a number of distinguishing clinical features, such as an early age of onset compared with sporadic cases; a higher prevalence of bilateral breast cancer; and the presence of associated cancers in some affected individuals, specifically ovarian cancer and possibly colon and prostate cancers. The two most common mutations are 185delAG and 5382insC, which account for 10% of all the mutations seen in BRCA1. These two mutations occur at a 10-fold higher frequency in the Ashkenazi Jewish population than in non-Jewish Caucasians. The carrier frequency of the 185delAG mutation in the Ashkenazi Jewish population is 1% and, along with the 5382insC mutation, accounts for almost all BRCA1 mutations in this population. Analysis of germline mutations in Jewish and non-Jewish women with early-onset breast cancer indicates that 20% of Jewish women who develop breast cancer before age 40 years carry the 185delAG mutation. There are founder BRCA1 mutations in other populations including, among others, Dutch, Polish, Finnish, and Russian populations.

Answer 30

BRCA2 is located on chromosome arm 13q, and spans a genomic region of approx. 70kb of DNA. The 11.2-kb coding region gontains 26 coding exons, and encodes a protein of 3418 amino acids. It is postulated to play a role in DNA damage response pathways. BRCA2 messenger RNA also is expressed at high levels in the late G1 and S phases of the cell cycle. The breast cancer risk for BRCA2 mutation carriers is close to 85%. The lifetime ovarian cancer risk is lower than for BRCA1, but is still estimated to be close to 20%. 50% of children of carriers inherit the trait. Unlike male carriers of BRCA, men with germline mutations in BRCA2 have an estimated breast cancer risk of 6% (100-fold increase over the risk in the general male population). BRCA2 associated breast cancers are invasive ductal carcinomas, which are more likely to be well-differentiated and to express hormone receptors that are BRCA-1 associated. BRCA2 associtated breast cancer has a number of distinguishing features: - Early age of onset - Higher prevalence of bilateral breast CA - Presence of associated cancers in some affected individuals (ovarian, colon, prostate, pancreatic, GB, bile duct, stomach, melanoma) Founder mutations identified in BRCA2 include: - 6174delT mutation (Ashkenazi Jews) - 1.2% (60% of ovarian CA and 30% of early onset breast CA) - 999del5 - Icelandic and Finnish populations

Answer 31

1. Obtain a complete multigenerational family history 2. Assess appropriateness of genetic testing for a particular patients 3. Counsel the patient 4. Interpret testing results Genetic testing should be offered only in conjunction with patient education and counseling, including referral to a genetic counselor. A thorough and accurate family history is crucial, because 50% of women with a BRCA mutation have inherited the mutation from their fathers.

Answer 32

If a family includes: 1) Ashkenazi Jewish heritage 2) A first degree relative with breast cancer before age 50 3) A history of ovarian cancer at any age in the patient or first or second degree relative with ovarian cancer 4) Breast and ovarian cancer in the same individual 5) 2 or more first or second degree relatives with breast cancer at any age 6) Patient or relative with bilateral breast cancer 7) Male breast cancer in a relative at any age The threshold for genetic testing is lower in individuals who are members of ethnic groups in whom the mutation prevalence is increased.

Answer 33

Gene sequence analysis

Answer 34

A familial cancer is caused by an identifiable BRCA mutation, but an individual tested had sporadic cancer. This is possible if the individual tested developed breast cancer close to the age of onset of the general population (age 60 years or older) rather than before age 50 years, as is characteristic of BRCA mutation carriers.

Answer 35

1) Risk-reducing mastectomy and reconstruction 2) Risk-reducing salpingo-oophorectomy 3) Intensive surveillance for breast and ovarian cancer 4) Chemoprevention

Answer 36

1) Clinical breast examination every 6 months 2) Mammography every 12 months beginning at age 25 (The risk of breast CA in carriers increases after age 30) 3) Annual MRI in women with a 20-25% or greater lifetime risk of developing breast cancer (mainly based on family history), women with a known BRCA1 or BRCA2 mutation, those with a first degree relative with a BRCA1 or BRCA2 mutation and have not had genetic testing themselves, those treated with RT to the chest between 10-30 years old, and those with Li-Fraumeni/Cowden/Bannayan-Riley-Ruvacalba syndrome, or a first degree relative with one of these syndromes.

Answer 37

20-40% (10x higher than in the general population) Risk-reducing salpingo-oophorectomy is a reasonable prevention option in mutation carriers. In women with a documented BRCA1 or BRCA2 mutation, consideration for bilateral risk-reducing salpingo-oophorectomy should be between 35-40 years old, and at the completion of childbearing. Hormone replacement therapy is discussed with the patient at the time of oophorectomy.

Answer 38

Yearly transvaginal ultrasound timed to avoid ovulation and annual measurement of serum cancer antigen 125 levels, beginning at age 25 years.

Answer 39

At approximately the 20th cell doubling, breast cancers acquire their own blood supply. Thereafter, cancer cells may be shed directly into the systemic venous blood to seed the pulmonary circulation via the axillary and intercostal veins or the vertebral column via Batson's plexus of veins, which courses the length of the vertebral column.

Answer 40

After the primary cancer exceeds 0.5cm, which corresponds to the 27th cell doubling.

Answer 41

The occurence of a second breast cancer outside the breast quadrant of the primary cancer (or at least 4cm away). This occurs in 60-90% of women with LCIS, and 40-80% of those with DCIS. LCIS occurs bilaterally in 50-70% of cases, while DCIS occurs bilaterally in 10-20% of cases.

Answer 42

The occurence of a second cancer within the same breast quadrant as the primary cancer (or within 4cm of it).

Answer 43

LCIS originates from terminal duct lobule units, and develops only in the female breast. It is characterized by distention and distortion of the terminal duct lobular units by cells that are large, but maintain a normal nuclear to cytoplasmic ratio. Cytoplasmic mucoid globules are a distinctive cellular feature. Neighborhood calcification (LCIS may be observed in tissues with microcalcifications, but the calcifications associated with LCIS typically occur in adjacent tissues) is a feature unique to LCIS. LCIS usually presents as an incidental finding, diagnosed on average at 45 years, 12x more frequently in white women. Invasive breast cancer develops in 25-35% of women with LCIS, with 65% of subsequent cancers becoming ductal in origin. Hence LCIS is regarded as a marker of increased risk rather than as an anatomic precursor. Individuals should be counseled regarding their risk of developing breast cancer and appropriate risk reduction strategies.

Answer 44

Predominantly seen in female breast CA, DCIS accounts for 5% of male breast cancers. It is characterized by a proliferation of minor ductal epithelium, resulting in papillary growths within the duct lumina. These papillary growths eventually coalesce and fill the duct lumina so only scattered rounded spaces remain between the clumps of atypical cancer cells, which show hyperchromasia and loss of polarity (cribriform growth pattern). Eventually pleomorphic cancer cells obliterate the lumina and distend the ducts (solid growth pattern). With continued growth, these cells outstrip the blood supply and become necrotic (comedo growth pattern). Calcium deposition occurs in necrotic areas and is a common feature on mammography. The risk for invasive breast cancer is increased nearly fivefold in women with DCIS. The invasive CA are observed in the ipsilateral breast, usually the same quadrant as the DCIS (suggesting DCIS as an anatomic precursor).

Answer 45

1) COMEDO - High nuclear grade - Extensive necrosis - High DCIS grade 2) INTERMEDIATE - Intermediate nuclear grade - Focal or absent necrosis - Intermediate DCIS grade 3) NONCOMEDO (solid, cribriform, papillary, or focal micropapillary) - Low nuclear grade - Absent necrosis - Low DCIS grade

Answer 46

Paget's disease of the nipple frequently presents as a chronic, eczematous eruption of the nipple, which may be subtle but may progress to an ulcerated, weeping lesion. It is usually associated with extensive DCIS and may be associated with an invasive cancer. A palpable mass may or may not be present. A nipple biopsy specimen will show a population of cells that are identical to the underlying DCIS cells (pagetoid features or pagetoid change). Pathognomonic of this cancer is the presence of large, pale, vacuolated cells (Paget cells) in the rete pegs of the epithelium. Paget's disease may be confused with superficial spreading melanoma. Differentiation from pagetoid intraepithelial melanoma is based on the presence of S-100 antigen immunostaining in melanoma and carcinoembryonic antigen immunostaining in Paget's disease. Surgical therapy for Paget's may involve lumpectomy or mastectomy, depending on the extent of involvement of the NAC and the presence of DCIS or invasive cancer in the underlying breast parenchyma.

Answer 47

Invasive ductal carcinoma of the breast with productive fibrosis (scirrhous, simplex, NST), accounts for 80% of breast cancers, and presents with macroscopic or microscopic axillary lymph node mets in up to 25% of screen-detected cases, and up to 60% of symptomatic cases. It occurs most frequently in perimenopausal or postmenopausal women in the 5th-6th decades of life as a solitary, firm mass. It has poorly defined margins, and its cut surfaces show a central stellate configuration with chalky white or yellow streaks extending into the surrounding breast tissues. The cancer cells often are arranged in small clusters and there is a broad spectrum of histologic types with variable cellular and nuclear grades. 75% of ductal cancers showed estrogen receptor expression.

Answer 48

Medullary cancer is a special type breast cancer, which accounts for 4% of all invasive breast cancers and is a frequent phenotype of BRCA1 hereditary breast cancer. Grossly the cancer is soft and hemorrhagic. A rapid increase in size may occur secondary to necrosis and hemorrhage. On PE, it is bulky and often positioned deep within the breast. Bilaterality is reported in 20% of cases. It is characterized microscopically by: a) a dense lymphoreticular infiltrate composed predominantly of lymphocytes. b) large pleomorphic nuclei that are poorly differentiated and show active mitosis c) a sheet-like growth pattern with minimal or absent ductal or alveolar differentiation. 50% are associated with DCIS, which characteristically is present at the periphery of the cancer, and <10% demonstrate hormone receptors. There is an intense lymphocytic response, hence benign or hyperplastic enlargement of the LN of axilla may contibute to erroneous clinical staging. Patients have a better 5-year survival rate than those with NST or invasive lobular carcinoma.

Answer 49

Mucinous/colloid caricnoma accounts for 2% of all invasive breast cancers and typically presents in the older population as a bulky tumor. This is defined by extracellular pools of mucin, which surround aggregates of low-grade cancer cells. Cut surface shows a glistening and gelatinous quality. Fibrosis is variable, and when abundant it imparts a firm consistency to the cancer. Over 90% of mucinous carcinomas display hormone receptors. Lymph node mets occur in 33% of cases, and 5 and 10 year survival rates are 73% and 59%, respectively. Because of the mucinous component, cancer cells may not be evident in all microscopic sections, hence analysis of multiple sections is essential to confirm the diagnosis.

Answer 50

Papillary carcinoma of the breast is a special type cancer that accounts for 2% of all invasive breast cancers. It generally presents in the seventh decade of life, and occurs in nonwhite women. These are small (<3cm) and are defined by papillae with fibrovascular stalks and multilayered epithelium. 87% express estrogen receptor. They have frequent axillary mets and similar 5-10year survival rates to mucinous and tubular carcinoma.

Answer 51

Tubular carcinoma of the breast is another special type breast cancer and accounts for 2% of all invasive breast cancers. It is reported in as many as 20% of women whose cancers are diagnosed by mammographic screening and usually is diagnosed in the perimenopausal or early menopausal periods. 94% of tubular cancers express estrogen receptor. 10% of women with tubular carcinoma or invasive cribriform carcinoma will develop axillary lymph node metastases. However the presence of metastatic disease in one or two axillary lymph nodes does not adversely affect survival. Distant metastases are rare in tubular carcinoma and invasive cribriform carcinoma. Long term survival approaches 100%.

Answer 52

Invasive lobular carcinoma accounts for 10% of breast cancers. The histopathologic features include small cells with rounded nuclei, inconspicuous nucleoli, and scant cytoplasm. Special stains may confirm the presence of intracytoplasmic mucin, which may displace the nucleus (signet-ring cell carcinoma). It is often multifocal, multicentric, and bilateral. Because of its insidious growth pattern and subtle mammographic features, invasive lobular cancers express estrogen receptor.

Answer 53

The MLO view images the greatest volume of breast tissue, including the upper outer quadrant and the axillary tail of Spence. Compared with the MLO view, the CC view provides better visualization of the medial aspect of the breast and permits greater breast compression. Other views include the 90deg lateral and spot compression views. The 90deg lateral view is used along with the CC view to triangulate the exact location of an abnormality. Spot compression may be done in any projection by using a small compression device, which is placed directly over a mammographic abnormality that is obscured by overlying tissues. Mammography is also used to guide interventional procedures including needle localization and needle biopsy.

Answer 54

1) A solid mass with/without stellate features 2) Asymmetric thickening of breast tissues 3) Clustered microcalcifications 4) Fine, stippled calcium in and around a suspicious lesion (50% of nonpalpable cancers)

Answer 55

Normal-risk women ≥20 years old should have a breast exam at least every 3 years. Starting at age 40 years, breast examinations should be performed yearly, and a yearly mammogram should be taken. Screening mammography in women ≥50 years old has been noted to reduce breast cancer mortality by 20-25%.

Answer 56

Nipple discharge, particularly when the fluid contains blood. In ductography, cancers may appear as irregular masses or multiple intraluminal filling defects.

Answer 57

Ultrasonography is an important method of resolving equivocal mammographic findings, defining cystic masses, and demonstrating the echogenic qualities of specific solid abnormalities. On ultrasound, breast cysts are well-circumscribed, with smooth margins and an echo-free center. Benign breast masses show smooth contours, round or oval shapes, weak internal echoes, and well-defined anterior and posterior margins. Breast cancer characteristically has irregular walls, but may have smooth margins with acoustic enhancement. Ultrasonography is used to guide fine-needle aspiration biopsy, CNB, and needle localization of breast lesions. It has highly reproducible findings, and a high patient acceptance rate, but it does not reliably detect lesions ≤1cm in diameter. It can also be used to image the regional lymph nodes in patients with breast cancer. (Sensitivity of 35-82%, and specificity of 73-97%).

Answer 58

``` Cortical thickening Change in shape of node to more circular appearance >10mm in size Absence of a fatty hilum Hypoechoic internal echoes ```

Answer 59

There is current interest in the use of MRI to screen breasts of high-risk women and women with a newly diagnosed breast cancer (MRI of the contralateral breast in women with a known breast CA has shown a contralateral cancer in 5.7% of these women). Some scenarios where MRI may be useful include: evaluation of a patient with nodal mets from breast CA without an identifiable primary, to assess response to therapy in the setting of neoadjuvant systemic treatment, to select patients for partial breast irradiation techniques, and evaluation of treated breast for tumor recurrence. From NCCN: 1) Useful in finding a primary breast lesion for patients with positive malignant axillary nodes, but negative clinical/imaging evidence of a primary tumor. 2) More accurate than mammogram in assessing extent of primary tumor in young women (dense breast tissue) and in diagnosis of invasive lobular carcinoma (>90% sensitivity). 3) Early detection of cancer in patients with BRCA mutation

Answer 60

The Oncotype DX is a 21-gene RT-PCR-based assay approved for use in newly diagnosed patients with node-negative, ER-positive breast cancer. A recurrence score is generated, and those patients with high recurrence scores are likely to benefit from chemotherapy. Those with low recurrence scores benefit most from endocrine therapy and may not required chemotherapy. The Trial Assessing Individualized Options for Treatment for breast cancer (TAILORx), designed to prospectively validate the use of 21-gene expression assay, have shown that patients with low recurrence score (0-10) have a low rate of local-regional and distant recurrence (98.7%) and very good overall survival at 5 years (98%) with endocrine therapy alone. Retrospective analysis has also shown that the 21-gene recurrence score can be use in postmenopausal patients with ER-positive tumors and 1-3 involved axillary lymph nodes to predict the benefit of chemotherapy in addition to endocrine therapy.

Answer 61

The MammaPrint assay uses a 70-gene expression profile to assess the risk of distant metastasis. This is FDA approved for use in stage 1 or stage 2 node negative, ER-positive, or ER-negative breast cancers to identify patients with high or low risk of recurrence. The prospective RASTER study reported that patients classified as low risk based on MammaPrint had a 97% distant recurrence-free interval at five years. Results of the prospective MINDACT (MicroarrayInNode negative and 1-3 positive lymph node Disease may Avoid ChemoTherapy) trial were recently reported. The study was designed to assess whether the 70-gene expression assay would help avoid chemotherapy in patients considered clinically high risk but categorized as low genomic risk based on the assay. A 5-year rate of distant metastasis-free survival of >92% was identified as the cutoff for the benefit of chemotherapy.

Answer 62

Stage 0 LCIS (marker for increased risk, 9-fold increased risk for CA) Goal: Prevent or detect at an early stage the invasive cancer that subsequently develops in 25-35% of women DX: 1) History and PE 2) Diagnostic bilateral mammography 3) Observation with interval history and PE every 6-12months 4) Annual mammogram ``` TX: Advise regarding risk for Breast CA: - Chemoprevention - Bilateral total mastectomy - Consider tamoxifen ``` There is NO benefit to excising LCIS because the disease diffusely involves both breasts in many cases and the risk of developing cancer is equal for both breasts.

Answer 63

Stage 0 DCIS (10-fold increased risk for CA) DX: 1) History & PE 2) Diagnostic bilateral mammography 3) ER status 4) MRI as indicated TX: With evidence of extensive disease (>4cm or in >1 quadrant) 1) Mastectomy 2) Adjuvant tamoxifen therapy (if ER positive) Limited disease 1) Lumpectomy 2) Radiation therapy 3) Adjuvant tamoxifen therapy (if ER positive) Nonpalpable DCIS 1) Needle-localization/ image-guided techniques 2) Specimen mammography is performed to ensure that all visible evidence of cancer is excised. 3) Adjuvant tamoxifen therapy (if ER positive) The gold standard against which breast conservation therapy for DCIS is evaluated is mastectomy. Women treated with mastectomy have local recurrence and mortality rates of <2%.

Answer 64

The Eastern Cooperative Oncology group (ECOG) initiated a prospective registry trial (ECOG 5194) to identify those patients who could safely undergo breast-conserving surgery without radiation. Eligible patients were those with low or intermediate grade DCIS measuring 2.5cm or less, who had negative margins of at least 3mm and those with high grade DCIS who had tumors measuring 1cm or less with a negative margin of at least 3mm. At a median follow up of 6.2 years, patients with low or intermediate grade DCIS had an in-breast recurrence rate of 6.1% while those with high-grade DCIS had a recurrence rate of 15.3%. Approximately 4% of patients developed a contralateral breast cancer during follow up in both low/intermediate and high-grade groups. This study identified an acceptable recurrence rate for those patients with low or intermediate grade DCIS treated with excision alone with a margin of at least 3mm. In contrast, patients with high-grade DCIS had an unacceptable high local recurrence rate.

Answer 65

The role of axillary staging in patients with DCIS is limited. One consideration is for patients undergoing mastectomy. Since most lesions are currently diagnosed with needle core biopsy, there is about a 20% incidence of invasive breast cancer on final pathologic assessment of the primary tumor. Since it is not feasible to perform sentinel node dissection after mastectomy, most surgeons will recommend the use of sentinel node dissection at the time of mastectomy for DCIS.

Answer 66

DX 1) History & PE 2) Diagnostic bilateral mammogram 3) Breast UTZ as necessary 4) ER-PR status determination 5) HER2 status determination 6) Pathology review TX: 1) Mastectomy with Axillary Staging (SLN dissection for clinically N0 patients-- ie, Modified Radical Mastectomy) or 2) Breast Conserving Surgery (Lumpectomy or Wide Excision + RT or + SLNB) - Not advised in women who are known BRCA mutation carriers, due to high lifetime risk for development of additional breast cancers. + Reconstruction If post-mastectomy RT is needed, a tissue expander can be placed at the time of mastectomy to save the shape of the breast and reduce the amount of skin replacement needed. The expander can be deflated at the initiation of radiation therapy to allow for irradiation of the chest wall and regional nodal basins. Removal of the tissue expander and definitive reconstruction, usually with autologous tissue, can proceed 6 months to 1 year after completion of RT.

Answer 67

1) Prior radiation therapy to the breast or chest wall 2) Persistently positive surgical margins after re-excision 3) Multi-centric disease 4) Scleroderma or lupus erythematosus

Answer 68

Adjuvant chemotherapy should be considered for patients with: 1) Positive lymph nodes 2) ER-negative disease 3) HER2-positive disease 4) Adjuvant! Online mortality >10% 5) Grade 3 node-negative tumors >5mm 6) Triple negative tumors 7) Lymphovascular invasion 8) Estimated distant relapse risk of >15% at 10 years based on the 21 gene recurrence score assay NCCN: 1) >2cm tumor 2) Poor histologic & nuclear grade 3) Negative hormone receptors 4) High proliferative fraction 5) HER2 expression 6) All node positive tumors

Answer 69

Adjuvant endocrine therapy is considered for: Hormone (+) cancers (Aromatase inhibitor if patient is postmenopausal) HER2/neu status is determined for all patients with newly diagnosed invasive breast cancer and when positive, should be used to guide systemic therapy recommendations.

Answer 70

1) Diffuse, suspicious mammographic calcifications 2) Inability to obtain clear margins on wide excision 3) Poor cosmetic result 4) Contraindications to RT 5) Patient's choice

Answer 71

1) ≥ 4 positive nodes 2) >5cm tumors (T3) 3) Very aggressive histology (diffuse vascular invasion) 4) Extranodal extension 5) Positive surgical margins 6) Inflammatory breast cancer 7) Involvement of skin, pectoral fascia, or skeletal muscle

Answer 72

Atypical ductal/lobular hyperplasia has a 4-fold increased risk for malignancy. TX: 1) Wire-localized excisional biopsy 2) Start Tamoxifen 20mg/day x 5 years

Answer 73

1) Age 2) Age at Menarche 3) Age at first live birth 4) Family history 5) Number of breast biopsies

Answer 74

``` Stage I: 95-100% Stage II: 80-90% Stage III: 50-70% Stage IV: 1-20% Tis: 98-100% ```

Answer 75

Skin-sparing mastectomy is the excision of nipple/areola complex + skin around biopsy site, + skin within 1-2cm of tumor margin. 5-10% of skin is removed. May include SLNB (if positive--> ALND). Candidates: 1) Multicentric disease 2) Invasive CA with extensive intraductal component 3) T2 tumors with difficult to interpret mammograms 4) Central tumors requiring removal of nipple-areola complex

Answer 76

1) No clinical involvement of NAC 2) <5cm tumor 3) Tumor-nipple distance ≥2cm

Answer 77

1) Clinically positive nodes at diagnosis, confirmed by FNAB or CNB 2) Sentinel nodes not identified In the absence of gross disease in level II nodes, dissection should include tissue inferior to the axillary vein from the lat dorsi, laterally to the medial border of the pex minor.

Answer 78

1) Locally advanced or inoperable breast tumors (inflammatory breast CA) 2) N2-N3 disease 3) T4 tumors 4) Operable breast CA who are clear candidates for adjuvant chemotherapy, and desire BCT 5) Breast cancer subtype with high likelihood of response

Answer 79

1) Aromatase inhibitor x 5 year 2) Tamoxifen x 2-3 years followed by: - AI x 5 years or - Tamoxifen x 4.5-6 years followed by AI x 5 years or - Tamoxifen x 10 years

Answer 80

AIs block conversion of adrenally synthesized androgens to estrogen (final step to conversion to active form of the hormone).

Answer 81

1) Tamoxifen x 5 years, with or without suppression (adjuvant) or 2) Ovarian suppression + AI x 5 years

Answer 82

Tamoxifen 20mg/tab OD Tamoxifen is a competitive ER antagonist. Side effects: Hot flushes, vaginal dryness/discharge, thromboembolic events, endometrial CA

Answer 83

DX: 1) History & PE 2) CBC 3) Liver FT + Alk phos 4) Chest imaging 5) Pathology review 6) Pre-chemo ER/PR status, HER2 status 7) Diagnostic bilateral mammogram 8) UTZ as necessary TX: 1) Neoadjuvant chemotherapy (Anthracycline based) 2) Modified Radical Mastectomy 3) Adjuvant RT 4) Endocrine/Trastuzumab therapy as warranted. If no response to adjuvant tx: 1) Additional chemotx or 2) Preoperative RT

Answer 84

1) History & PE 2) Mammogram annually 3) If on Tamoxifen: annual gynecologic assessment 4) If on AI: Bone health + bone mineral density tests 5) Active lifestyle, healthy diet, maintain IBW (20-25 BMI)

Answer 85

DX: 1) History & PE 2) CBC 3) LFTs 4) Chest CT 5) Bone Scan 6) X-ray of painful weight bearing bones 7) Biopsy documentation of mets if possible 8) ER-PR, HER-2 status TX: 1) Endocrine treatment 2) Systemic chemotherapy 3) Bisphosphonates (Bone mets)

Answer 86

DX: 1) History & PE 2) UTZ 3) Mammogram if ≥30 years old 4) Core needle biopsy TX: 1) Wide excision 2) Mastectomy for larger lesions Recurrence: Positive Mets: Follow soft tissue sarcoma guidelines Negative Mets: Re-excision with wide margins ≥1cm Negative axillary staging, consider postop RT

Answer 87

Rare manifestation of cancer, neoplastic cells in the epidermis of the nipple-areolar complex. Presents with eczema, bleeding, ulceration, itching. Associated cancer in the breast elsewhere in up to 80-90% of cases. DX: 1) History & PE and Imaging (+) for breast mass: Core needle biopsy of lesion + full thickness skin 2) History & PE and Imaging (-) for breast mass: Full-thickness biopsy 3) Biopsies (-) for CA, but (+) for Paget's: Breast MRI and tissue sampling TX: 1) (-) Mass or imaging abnormality: Central lumpectomy (NAC + margin of underlying breast tissue) 2) Mass in other part of the breast: Removal of NAC + negative margins + BCS for peripheral CA 3) Mastectomy (if DCIS)

Answer 88

Breast cancer during pregnancy is often ALN-positive, larger primary tumor size, and often with poorly differentiated tumors. DX: 1) History & PE of breast and lymph node status 2) Mammogram with shielding 3) Ultrasound of breast and LN 4) FNAB or CNB (preferred) with ER-PR/HER2 analysis 5) CXR with shielding, include FTs and renal FTs, CBC (T1-T2) 6) Add liver UTZ and thoracolumbar MRI without contrast (N+ or T3) TX: 1) BCS (Lumpectomy/wide excision + RT; RT can be delayed to postpartum) 2) MRM 3) Chemotherapy: For 2nd and 3rd trimesters ONLY with fetal monitoring prior to each chemo (BUT NOT >35 weeks AOG to prevent bleeding) CONTRAINDICATIONS - Trastuzumab, RT, AI, Tamoxifen: ONLY POSTPARTUM - SLNB: Contraindicated for <30 weeks AOG - Chemotherapy: Contraindicated for 1st trimester and after 35 weeks AOG.

Answer 89

IBC presents as erythema and dermal edema of ≥1/3 of skin of breast. It is often ER-PR/HER2 +. Considered as IIIB, IIIC, or Stage IV (T4d), is comprises <3% of breast CA. It is caused by blockage of lymph by tumor emboli. DX: 1) History & PE 2) CBC + Plt 3) Pathology review (ER-PR/HER2) 4) Diagnostic bilateral mammogram 5) UTZ & MRI as necessary 6) Mets workup: LFTs, Bone scan, Chest/Abd/Pelvic CT, PET/CT for equivocal findings TX: 1) Neoadjuvant chemotherapy 2) Mastectomy (with I/II ALND, ie MRM) 3) RT 4) HER2 therapy if (+)

Answer 90

SLND is used to assess the regional LN in early breast cancer who are clinically node negative. Contraindications to SLND: 1) Inflammatory breast CA 2) Palpable axillary lymph nodes 3) Biopsy-proven metastases 4) DCIS without mastectomy 5) Prior axillary surgery Tumors in lateral breast are likely to have a false negative SLN.

Answer 91

0: Incomplete 1: Normal 2: Benign 3: Probably Benign 4: Possibly Malignant (Suspicious) 5: Malignant (Highly suspicious) 6: Malignant Tissue

Answer 92

The binding of estrogen to its receptor induces PR expression. The presence of both receptors in a tumor indicates an 80% chance of a favorable response to endocrine therapy. LUMINAL A (ER+ PR+ HER2-) - low-grade, 40% of all breast CA - good prognosis - TX: 1) Premenopause: SERMs (Tamoxifen) 2) Postmenopause: AIs (Anastrozole, Exemestane, Letrozole) LUMINAL B (ER+ PR+/- HER2+/-) - higher grade, 20% - poorer prognosis - TX: 1) Tamoxifen (decreased response) 2) Chemotherapy (increased response to chemo) HER2-ENRICHED (ER- PR- HER2+) - High-grade, often node positive - p53 mutations - 10-15% of all breast CA - TX: Trastuzumab, Pertuzumab, Lapatinib BASAL-LIKE (ER- PR- HER2-) - Triple negative - High proliferation, BRCA dysfunction - 15-20% - Poor prognosis - TX: Chemotherapy

Answer 93

Oncotype Dx (21-gene assay) is the only assay clinically validated, using a 21-gene recurrence score (RS) for: 1) Predicting the benefit of adding adjuvant chemotherapy to adjuvant endocrine therapy, to further reduce the risk of recurrence in women with HR-positive, HER2-negative and node-negative breast cancer. 2) Determining the prognosis in women with HR-positive, HER2-negative tumors treated with endocrine therapy alone by predicting locoregional and distant recurrence.

Answer 94

MammaPrint (70-gene assay) can identify a subset of patients who have a low likelihood of distant recurrence despite a high risk clinical features (based on tumor size, grade and nodal status).

Answer 95

Adjuvant! Online is a validated computer-based model available to estimate 10-year DFS and OS that incorporates all of the above prognostic factors except for HER2 tumor status.

Answer 96

Response Evaluation Criteria in Solid Tumors (RECIST) was introduced in 2000 to standardize and simplify tumor response criteria. V 1.1 (2020) TARGET LESIONS CR: Disappearance of all target lesions and reduction in the short axis measurement of all pathologic lymph nodes to ≤10 mm PR: ≥30% decrease in the sum of the longest diameter of the target lesions compared with baseline PD: ≥20% increase of at least 5 mm in the sum of the longest diameter of the target lesions compared with the smallest sum of the longest diameter recorded or The appearance of new lesions, including those detected by FDG-PET SD: Neither PR nor PD --- NON-TARGET LESIONS CR: Disappearance of all non-target lesions and normalization of tumor marker levels IR, SD: Persistence of 1 or more non-target lesions and/or the maintenance of tumor marker levels above normal limits PD: The appearance of 1 or more new lesions or unequivocal progression If patient has measurable disease, an increase in the overall level or substantial worsening in non-target lesions, such that tumor burden has increased, even if there is SD or PR in target lesions If no measurable disease, an increase in the overall tumor burden comparable in magnitude with the increase that would be required to declare PD in measurable disease (eg, an increase in pleural effusions from trace to large, or an increase in lymphangitic disease from localized to widespread)

Answer 97

Women with hormone receptor positive cancers with no immediate life-threatening disease (or visceral crisis) (ie, only bone or soft tissue mets, and those with limited visceral mets).

Answer 98

Women with hormone receptor-negative cancers, visceral crisis, and hormone-refractory metastases.

Answer 99

Bisphosphonates | Anti-RANKL (Receptor Activator of Nuclear Factor Kappa-B Ligand) agent, Denosumab

Answer 100

Women post-mastectomy: - Surgical resection of local-regional recurrence and reconstruction - Consider chemotherapy and antiestrogen therapy - Adjuvant RT if no previous RT Women post-lumpectomy/BCS: - Mastectomy - Reconstruction - Consider chemo and antiestrogen therapy depending on hormone status and HER2 status of the tumor.

Answer 101

When needle biopsy results are discordant with imaging findings or PE.

Answer 102

Radial incisions

Answer 103

Because of possible scar contracture resulting in displacement of the ipsilateral nipple-areola complex. Similarly, curvilinear incisions in the lower half of the breast may displace the NAC downward.

Answer 104

Studies have demonstrated that 98% of all positive SLNs will be recovered with the removal of 4 SLNs. Therefore, it is not necessary to remove greater than 4 SLNs for accurate staging of the axilla.

Answer 105

A skin-sparing mastectomy removes all breast tissue, NAC, and scars for prior biopsy procedures. There is a recurrence rate of <6-8%, comparable to the long-term recurrence rates of standard mastectomy, when skin-sparing mastectomy is used for patients with Tis to T3 cancers.

Answer 106

A total (simple) mastectomy without skin sparing removes all breast tissue, the NAC, and skin.

Answer 107

An extended simple mastectomy removes all breast tissue, the NAC, skin, and level I axillary lymph nodes.

Answer 108

An MRM removes all breast tissue, the NAC, skin, and levels I, II, and III axillary lymph nodes. The pectoralis minor divided and removed by Patey may be simply divided, giving improved access to level III nodes, then left in situ, or occasionally the axillary clearance can be performed without dividing pectoralis minor.

Answer 109

The Halsted radical mastectomy removes all breast tissue and skin, the NAC, the pectoralis major and minor muscles, and levels I, II, and III axillary lymph nodes. The use of systemic chemotherapy and hormonal therapy as well as adjuvant radiation therapy for breast cancer have nearly eliminated the need for radical mastectomy.

Answer 110

Nipple-areolar sparing mastectomy has been popularized over the last decade especially for risk-reducing mastectomy in high-risk women. Factors for eligibility: 1) Tumor located >2 to 3cm from the border of the areola 2) Smaller breast size 3) Minimal ptosis 4) No prior breast surgeries with periareolar incisions 5) BMI <40kg/m^2 6) No active tobacco use 7) No prior breast irradiation 8) No evidence of collagen vascular disease

Answer 111

1) Anterior margin of the latissimus dorsi laterally 2) Midline of the sternum medially 3) Subclavius muscle superiorly 4) 2-3cm inferior to the inframammary fold inferiorly

Answer 112

7-8mm inclusive of skin and telasubcutanea. May differ with body habitus.

Answer 113

1) Adjuvant radiation therapy to the breast and supraclavicular lymph nodes after neoadjuvant chemotherapy, and segmental mastectomy with or without axillary node dissection 2) Adjuvant radiation therapy to the chest wall and supraclavicular lymph nodes after neoadjuvant chemotherapy and mastectomy with or without axillary lymph node dissection 3) Adjuvant radiation therapy to the chest wall and supraclavicular lymph nodes after segmental mastectomy or mastectomy with axillary lymph node dissection and adjuvant chemothearpy.q

Answer 114

1) Positive lymph nodes 2) HER2-positive disease 3) Adjuvant! Online greater mortality >10% 4) Grade 3 LN negative tumors >5mm 5) Triple-negative tumors 6) LV invasion 7) Estimated distant relapse risk of 15% at 10 years based on 21 gene recurrence score 8) Hormone receptor negative cancers >1cm

Answer 115

Preferred: 1) Dose dense AC --> Paclitaxel every 2 weeks 2) Dose dense AC --> Paclitaxel weekly 3) TC (T = docetaxel) Others: 1) CMF 2) AC --> Docetaxel every 3 weeks 3) AC --> Paclitaxel weekly 4) TAC (T = docetaxel)

Answer 116

Preferred: AC --> T + trastuzumab +/- pertuzumab (T = paclitaxel) TCH (docetaxel, carboplatin, trastuzumab +/- pertuzumab

Answer 117

TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis (DCIS): Ductal carcinoma in situ (DCIS) Tis (Paget): Paget disease of the nipple not associated with invasive carcinoma and/or carcinoma in situ (DCIS) in the underlying breast parenchyma. Carcinomas in the breast parenchyma associated with Paget disease are categorized based on the size and characteristics of the parenchymal disease, although the presence of Paget should still be noted. ``` T1: Tumor ≤20mm in greatest dimension T1mi: Tumor ≤1mm T1a: Tumor >1mm but ≤5mm T1b: Tumor >5mm but ≤10mm T1c: Tumor >10mm but ≤20mm ``` T2: Tumor >20mm but ≤50mm in greatest dimension T3: Tumor >50mm in greatest dimension T4: Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or macroscopic nodules); invasion of dermis alone does not qualify as T4 T4a: Extension to chest wall, invasion/adherence to pex in absence of chest wall structures does NOT qualify as T4 T4b: Ulceration and/or ipsilateral macroscopic satellite nodules and/or edema (inc peau d'orange) of the skin that does not meet criteria for inflammatory carcinoma T4c: Both T4a and T4b present T4d: Inflammatory carcinoma

Answer 118

cNX: Regional lymph nodes cannot be assessed (ie, previously removed) cN0: No regional lymph node mets (by imaging or clinical exam) cN1: Metastases to movable ipsilateral level I, II axillary lymph nodes cN1mi: Micrometastases cN2: Mets in ipsilateral level I, II axillary LNs that are clinically fixed or matted; or in ipsilateral internal mammary nodes in the absence of axillary LN mets cN2a: Mets in ipsilateral level I, II axillary LN fixed to one another (matted) or to other structures cN2b: Mets only in ipsilateral internal mammary nodes in the absence of axillary LN mets cN3: Mets in ipsilateral infraclavicular (level III axillary) LNs with or without level I, II axillary LN involvement; or in ipsilateral internal mammary LN with level I, II axillary LN mets; or mets in ipsilateral supraclavicular LN with or without axillary or internal mammary lymph node involvement cN3a: Mets in ipsilateral infraclavicular lN cN3b: Mets in ipsilateral internal mammary LNs and axillary LNs cN3c: Mets in ipsilateral supraclavicular LNs

Answer 119

M0: No clinical or radiographic evidence of distance metastases cMO(i+): No clinical or radiographic evidence of distant mets in the presence of tumor cells or deposits not larger than 0.2mm detected microscopically or by molecular techniques in circulating blood, bone marrow, or other nonregional nodal tissue in a patient without symptoms or signs of mets. cM1: Distant mets detected by clinical and radiographic means pM1: Any histologically proven mets in distant organs, or if in non-regional nodes, mets greater than 0.2mm.

Answer 120

Stage 0: Tis N0 M0 Stage IA: T1 N0 M0 Stage IB: T0-1 N1mi M0 Stage IIA: T0-1 N1 M0 T2 N0 M0 Stage IIB: T2 N1 M0 T3 N0 M0 Stage IIIA: T0-2 N2 M0 T3 N1-2 M0 Stage IIIB: T4 N0-2 M0 Stage IIIC: Any T N3 M0 Stage IV: Any T Any N M1

Answer 121

``` INVASIVE CANCER (Scarff-Bloom-Richardson Grading System, Nottingham Modification): GX: Grade cannot be assessed ``` G1: Low combined histologic grade (favorable); SBR score of 3-5 points G2: Intermediate combined histologic grade (moderately favorable); SBR score of 6-7 points G3: High combined histologic grade (unfavorable); SBR score of 8-9 points ``` DUCTAL CARCINOMA IN-SITU GX: Grade cannot be assessed G1: Low nuclear grade G2: Intermediate nuclear grade G3: High nuclear grade ```

Answer 122

They are scored as 3+ by an IHC method defined as uniform membrane staining for HER2 in 10% or more of tumor cells, or demonstrate HER2 gene amplification by an ISH method.

Answer 123

Scored as IHC 2+ based on circumferential membrane staining that is incomplete and/or weak/moderate and within greater than 10% of the invasive tumor cells, or complete and circumferential membrane staining that is intense and within less than or equal to 10% of the invasive tumor cells.

Answer 124

Anthracyclines (Doxorubicin)

Answer 125

Taxane chemotherapy (Paclitaxel)

Answer 126

When it is spontaneous, unilateral, localized to a single duct, present in ≥40yo, bloody, or associated with a mass. Mammography, ultrasound, and possibly a ductogram are indicated. Definitive diagnosis depends on excisional biopsy of the offending duct and any associated mass lesion. Localization with a wire or seed is performed when there is an associated mass that lies >2.0-3.0cm from the nipple.

Answer 127

When it is bilateral, multiductal in origin, occurs in women ≤39yo, or is milky or blue-green. Prolactin-secreting pituitary adenomas are responsible for bilateral nipple discharge in <2% of cases. If serum prolactin levels are repeatedly elevated, plain radiographs of the sella turcica are indicated, and thin section CT scan is required. Optical nerve compression, visual field loss, and infertility are associated with large pituitary adenomas.

Answer 128

A woman who presents with axillary lymph node mets consistent with a breast cancer metastasis has a 90% probability of harboring an occult breast cancer. However, axillary lymphadenopathy is the initial presenting sign in only 1% of breast cancer patients. The search for a primary cancer should include examination of the thyroid, breast, and pelvis, including rectum.

Answer 129

<1% of all breast cancers occur in men. Male breast cancer is preceded by gynecomastia in 20% of men. It is associated with radiation exposure, estrogen therapy, testicular feminizing syndromes, and Klinefelter's syndrome (XXY). Breast cancer is rarely seen in young males and has a peak incidence in the 6th decade of life. DCIS makes up <15% of male breast cancer, whereas infiltrating ductal carcinoma makes up >85%. Stage by stage, males have the same survival rate as women. Overall, men do worse because of the more advanced stage of their cancer (stage II, III or IV) at the time of diagnosis. 80% of male breast cancers are HR-positive, and adjuvant tamoxifen is considered.

Answer 130

>75% of women with inflammatory breast cancer present with palpable axillary lymphadenopathy, and distant mets are also frequently present.

Answer 131

c. Breast MRI

Answer 132

c. Core needle biopsy of the lesion

Answer 133

a. ER/PR (+), HER-2/neu (-)

Answer 134

b. Radiation plus chemotherapy

Answer 135

c. Chemotherapy

Answer 136

c. Lumpectomy and RT or simple mastectomy

Answer 137

d. Tamoxifen

Answer 138

b. lobular carcinoma in situ

Answer 139

d. Neoadjuvant chemotherapy followed by surgery and radiation therapy

Answer 140

b. Mammogram yearly starting at age 40

Answer 141

Ectodermal thickenings, termed mammary ridges or milk lines

Answer 142

Estrogen: branching differentiation and duct development in the breast Progesterone: lobular development of the breast

Answer 143

Lateral thoracic artery: Serratus anterior muscle Thoracodorsal artery: Latissimus dorsi

Answer 144

Serratus anterior muscle: Long thoracic nerve Latissimus dorsi: Thoracodorsal nerve Pectoralis minor: Medial pectoral nerve Pectoralis major: Lateral and medial pectoral nerves

Answer 145

Long thoracic nerve: Winged scapula | Thoracodorsal nerve: Weak arm adduction/pull-ups

Answer 146

Branches derived from the intercostal arteries, internal thoracic artery, lateral thoracic artery, and thoracoacromial artery

Answer 147

Batson plexus

Answer 148

Cooper ligaments

Answer 149

The axillary nodes: 97% | The internal mammary nodes: 1% to 2%

Answer 150

Level I: Lateral to the pectoralis minor muscle Level II: Beneath the pectoralis minor muscle Level III: Medial to the pectoralis minor muscle

Answer 151

Nodes between the pectoralis minor and major muscles

Answer 152

Superior: Axillary vein Posterior: Long thoracic nerve Lateral: Latissimus dorsi muscle Medial: Pectoralis minor

Answer 153

``` Long thoracic nerve Thoracodorsal nerve Medial pectoral nerve Lateral pectoral nerve Intercostobrachial nerve ```

Answer 154

``` Axillary vein thrombosis Infection Nerve injury Lymphedema Lymphatic fibrosis Lymphangiosarcoma ```

Answer 155

Axillary vein thrombosis

Answer 156

Lymphatic fibrosis

Answer 157

Injury to the second intercostobrachial cutaneous nerve

Answer 158

15% to 30%

Answer 159

90% for both

Answer 160

5 mm or greater

Answer 161

1 week after menstrual period

Answer 162

Initial screening mammogram at age 40 and annual mammograms after age 40

Answer 163

Mammogram 10 years before the youngest age of diagnosis of breast cancer in a first- degree relative

Answer 164

``` Asymmetric density Distortion of architecture Ductal asymmetry Irregular borders Multiple clusters Linear, small, thin, and/or branching calcifications Spiculations ```

Answer 165

Breast Imaging Reporting and Data System

Answer 166

BIRADS 0: Incomplete; follow-up imaging necessary BIRADS 1: Negative; routine screening BIRADS 2: Definite benign finding; routine screening BIRADS 3: Probably benign; 6-month short-interval follow-up BIRADS 4: Suspicious abnormality; biopsy should be considered BIRADS 5: Highly suspicious ofmalignancy; appropriate action should be taken BIRADS 6: Known biopsy-proven malignancy; ensure that treatment is completed

Answer 167

Comedo pattern

Answer 168

Excision with 2- to 3-mm margins ± radiation

Answer 169

Lumpectomy and radiation with 2- to 3-mm margins or total mastectomy without axillary dissection

Answer 170

Contraindications to radiation, | high grade, and diffuse breast involvement

Answer 171

Usually the ipsilateral breast

Answer 172

50% to 60%

Answer 173

Carcinoma can arise in either breast

Answer 174

False; considered a marker for the development of breast cancer but not premalignant

Answer 175

False; negative margins are not required

Answer 176

Ductal carcinoma (70%)

Answer 177

Close-interval follow-up, treatment with tamoxifen, or bilateral simple mastectomy

Answer 178

1 in 8 women; 12% lifetime risk

Answer 179

2 primary relatives with bilateral or premenopausal breast cancer BRCA gene in a patient with family history of breast cancer DCIS or LCIS Fibrocystic disease with atypical hyperplasia

Answer 180

Early menarche (<12 years) Late menopause (>55) Nulliparity (or first birth after age 30) Environmental risk factor (high-fat diet/obesity) Family history of breast cancer (excluding BRCA gene) 2 primary relatives with bilateral or premenopausal breast cancer Previous breast cancer Radiation

Answer 181

2 to 3 years

Answer 182

Upper outer quadrant (50%)

Answer 183

Nodal status

Answer 184

0 positive nodes: 75% 1 to 3positive nodes: 60% 4 to 10 positive nodes: 40%

Answer 185

T1 breast lesion: 52 cm T2 breast lesion: 2 to 5 cm T3 breast lesion: >5 cm T4 breast lesion: Skin/chest wall involvement (excluding pectoral muscles) Peau d orange: Inflammatory breast cancer

Answer 186

N1: Ipsilateral axillary nodes N2: Fixed ipsilateral axillary nodes N3: lpsilateral internal mammary nodes

Answer 187

Distant metastasis, including ipsilateral supraclavicular nodes

Answer 188

Infiltrating ductal carcinoma

Answer 189

Blood in cyst aspirate, bloody nipple discharge Dermatitis/ulceration of nipple Patient concern of persistent breast abnormality Persistent mass after aspiration Solid mass Suspicious lesion by imaging studies

Answer 190

These tumors are usually multicentric

Answer 191

``` Stage 0 breast cancer Tis, N0, M0 Stage I breast cancer T1, N0, M0 Stage Ila breast cancer T0- to T1, N1, M0 or T2, N0, M0 Stage IIb breast cancer T2, N1, M0 or T3, N0, M0 Stage Illa breast cancer T0 to 3, N2, M0 or T3, N1 to N2, M0 Stage Illb breast cancer Any T4 or N3 tumors Stage IV breast cancer M1 ```

Answer 192

5 to 7 years

Answer 193

Lymph nodes (most common} Brain Bones Liver Lung/pleura

Answer 194

Better overall prognosis and prognosis following surgery Better response to chemotherapy and hormone manipulation More well-differentiated tumor

Answer 195

Phyllodes tumor, medullary carcinoma, and adenoid cystic carcinoma

Answer 196

Wide local excision with 1-cm margin without axillary dissection

Answer 197

Fat necrosis, fibromatosis, granular cell tumor, radial scar

Answer 198

<1%of all breast cancer cases

Answer 199

``` BRCA2 carrier, estrogen therapy, gynecomastia (from increased estrogen}, increased estrogen, Klinefelter syndrome (XXY), radiation ```

Answer 200

Ductal carcinoma

Answer 201

False; prognosis is the same stage for stage (overall prognosis is poorer secondary to men presenting at a later stage)

Answer 202

40% versus 20%

Answer 203

Autosomal dominant transmission

Answer 204

False; they are incompletely penetrant, and some carriers may not develop cancer

Answer 205

Ashkenazi Jews (1%-3%)

Answer 206

Transmembrane tyrosine kinase receptor with potent growth-stimulating activity

Answer 207

Li-Fraumeni syndrome

Answer 208

Modified radical mastectomy

Answer 209

``` Medications (cimetidine, ketoconazole, spironolactone, TCAs), androgen insensitivity, gonadal failure, decreased testosterone, increased estrogen, illicit drugs (marijuana), liver failure ```

Answer 210

Stop/change medications, correct any hormonal imbalances/underlying cause; if refractory to time and conservative measures, perform a biopsy versus simple mastectomy

Answer 211

Excision of breast and nipple-areolar complex without removal of axillary nodes

Answer 212

Breast, nipple-areolar complex, and axillary nodes (level I, II)

Answer 213

Hematoma/seroma, infection, ipsilateral arm lymphedema, nerve injury, phantom breast syndrome, skin flap necrosis

Answer 214

Family history and BRCA-positive or LCIS with one of the following: • High patient anxiety • Lesion difficult to follow on exam/mammography • Poor access for follow-up • Patient preference for mastectomy

Answer 215

``` Tumor>5cm 4 or more positive lymph nodes Extracapsular nodal invasion Fixed axillary nodes (N2) or internal mammary nodes (N3) Inflammatory cancer Positive margins Skin/chest wall involvement ```

Answer 216

Cardiac toxicity, contralateral breast cancer, edema, erythema, pneumonitis, rib fractures, sarcoma, ulceration

Answer 217

An area with a history of prior therapeutic irradiation Diffuse, malignant-appearing microcalcifications Persistent positive margins after surgery Pregnancy (except in third trimester, can give radiation after delivery) 2 or more primary tumors in separate quadrants of the breast

Answer 218

Extensive gross multifocal disease in the same quadrant History of scleroderma or active systemic lupus erythematosus Large tumor in a small breast, if it would result in unacceptable cosmesis Genetic predisposition to breast cancer

Answer 219

Tumors <5 cm (stage I and II)

Answer 220

10%, usually within 2 years of the first operation

Answer 221

Salvage mastectomy

Answer 222

5% (4%-8%)

Answer 223

AC (Adriamycin and cyclophosphamide) followed by paclitaxel, TAC (Adriamycin, cyclophosphamide, and docetaxel), TC (docetaxel and cyclophosphamide), or CMF (cyclophosphamide, methotrexate, 5-fluorouracil)

Answer 224

20mg daily for 5 years

Answer 225

Postmenopausal women

Answer 226

Aminoglutethimide, anastrozole/letrozole (aromatase inhibitors), androgenic steroid, bilateral oophorectomy, Megace

Answer 227

1.35 (26% increased risk)

Answer 228

Node negative, low-risk breast cancer: No treatment or endocrine therapy if ER+ Node negative, higher risk ER+ breast cancer: Chemotherapy + endocrine therapy or endocrine therapy Node negative, higher risk ER- breast cancer: Chemotherapy Node positive, ER+ breast cancer in a premenopausal patient: Chemotherapy + endocrine therapy Node positive, ER+ breast cancer in a postmenopausal patient: Chemotherapy + endocrine therapy or endocrine therapy alone Node positive, ER- breast cancer: Chemotherapy

Answer 229

Chemotherapy plus trastuzumab (Herceptin)

Answer 230

First trimester: Modified radical mastectomy Second trimester: Modified radical mastectomy Third trimester: If late, can perform lumpectomy with ALND and postpartum radiation; otherwise, modified radical mastectomy

Answer 231

Primary tumors >5 cm, fixed or matted axillary nodes, and inflammatory breast carcinoma

Answer 232

Previous radiation therapy to breast or severe collagen vascular disease, pregnancy

Answer 233

Tamoxifen is a selective ER modulator and binds to and inhibits ER signaling in the breast. It produces antiestrogen effects in the breast. In postmenopausal women, the primary source of estrogen is from the conversion of androstenedione to estrone and testosterone to estradiol in peripheral tissues such as breast, skin, and adipose tissue by aromatase. The aromatase inhibitors block this conversion, explaining why they are only effective in postmenopausal women.

Answer 234

Osteoporosis, joint disorders, hypercholesterolemia

Answer 235

Prostate cancer is associated with both mutations. BRCA1: ovarian and endometrial. Consider prophylactic TAHBSO. BRCA2: male breast cancer, colon, pancreatic, stomach, gallbladder, melanoma

Answer 236

BRCA1: poorly differentiated, receptor-negative BRCA2: well-differentiated, receptor-positive

Answer 237

Dermatitis/scaling rash of the nipple caused by invasion of the skin by ductal carcinoma cells

Answer 238

Excision with sentinel lymph node (SLN) biopsy and radiation

Answer 239

Lymphangiosarcoma secondary to chronic lymphedema following axillary dissection

Answer 240

Mondor disease

Answer 241

Nonsteroidal antiinflammatory drugs (NSAIDs)

Answer 242

Fibroadenoma

Answer 243

Staphylococcus aureus

Answer 244

Antibiotics, continue breastfeeding, heating packs, utilization of breast pumps

Answer 245

To rule out inflammatory breast cancer

Answer 246

Accessory nipple

Answer 247

Poland syndrome

Answer 248

lntraductal papilloma

Answer 249

Resection (subareolar resection)

Answer 250

Fibrocystic disease

Answer 251

Evening primrose oil, danazol, OCP

Answer 252

3 to 4g daily

Answer 253

Fibroadenoma

Answer 254

Fibroadenoma

Answer 255

Infiltrating ductal carcinoma

Answer 256

Fibrocystic disease

Answer 257

Breast carcinoma

Answer 258

Fibroadenoma

Answer 259

Answer: D. If no tracer or blue dye is taken up by the lymph nodes, a lymph node dissection must be performed along with breast-conserving therapy (i.e., lumpectomy) and radiation.

Answer 260

Answer: E. Since the patient has positive nodal status, chemotherapy is necessary. Also undergoing breast-conserving therapy, the patient must receive radiation. Since she is premenopausal and her nodal status is positive, tamoxifen would also be given.

Answer 261

Answer: B. The patient has Paget disease that involves more than the nipple without evidence of malignancy; thus, the treatment is simple mastectomy.

Answer 262

Answer: C. Since the patient is in her second trimester, chemotherapy and radiation are contraindicated. She will need a modified radical mastectomy.

Answer 263

Answer: C. Even though her mammogram is BIRADS3, indicating a repeat mammogram in 6 months, the patient has a palpable mass. This alone necessitates immediate further workup with core needle biopsy.

Answer 264

Answer: D. The patient has developed Stewart-Treves syndrome (lymphangiosarcoma). Her treatment would include an open biopsy to confirm diagnosis followed by wide excision.

Answer 265

Answer: D. Given the patient's wish for breast conservation, neoadjuvant chemotherapy can be given in an attempt to downsize the tumor. After neoadjuvant chemotherapy, if there is an appropriate response by the tumor, breast conservation can be undertaken. An SLN biopsy should also be performed to assess the lymph node status.

Answer 266

Answer: A. This patient has spontaneous, unilateral, bloody nipple discharge, which is suspicious for an underlying malignancy. The most common cause of bloody nipple discharge is a benign, intraductal papilloma. Major duct excision is warranted because of the risk of malignancy in this patient. Ductography has only a 60% sensitivity for malignancy, but could be a consideration in a patient who wishes to preserve breastfeeding.

Answer 267

Answer: D. This patient has inflammatory breast cancer, and breast-conserving surgery is contraindicated. The management of inflammatory breast cancer is neoadjuvant chemotherapy followed by chemotherapy and radiation therapy.

Answer 268

Answer: C. In this patient with LCIS and an imaging abnormality, she will need a wider biopsy to rule out an associated cancer. A negative margin is not required at the excisional biopsy, since LCIS can be extensive. The goal of the biopsy is to obtain a larger specimen. If a malignancy is found, it should be appropriately treated.

Answer 269

Answer: C. The patient has Paget disease confined to the nipple without associated cancer, so the patient can be offered breast-conserving surgery but does need a sentinel lymph node biopsy.

Answer 270

Answer: A. Phyllodes rarely metastasizes, but if it does, it is via hematogenous spread. It has no nodal spread; therefore, lymph node dissection is not done.

Answer 271

Answer: D. The comedo pattern of DCIS is the most aggressive subtype with areas of necrosis seen on pathology.

Answer 272

Answer: B. The tubular subtype has the most favorable prognosis of ductal cancer.

Answer 273

Answer: D. The scirrhotic subtype has the worst prognosis of ductal cancer.

Answer 274

D. Wide excision and chemotherapy

Answer 275

C. Wide excision with margins

Answer 276

D. Locally recurrent breast mass would need chest imaging for metastatic workup.

Answer 277

A. Consider breast MRI and tissue sampling.

Answer 278

B. Pregnancy is not a contraindication for BCS.

Answer 279

B. Preoperative systemic therapy is recommended.

Answer 280

D. MRI is recommended to look for possible primary breast cancer.

Answer 281

D. Hormonal therapy

Answer 282

B. Recurrent cases would need culture and sensitivity tests.

Answer 283

D. The size of the lesion can be an indication for excision biopsy.

Answer 284

21. (B) Breast cysts are often well demarcated and tend to get larger and contain nonbloody fluid, which is usually acellular and cytology is rarely indicated. Galactoceles present in pregnant and nursing women are filled with milky fluid.

Answer 285

22. (C) Fibroadenomas are most often found in teenage girls. They are firm in consistency, clearly defined , and very mobile. The typical feature on palpation is that they appear to move freely through the breast tissue (“breast mouse”).

Answer 286

23. (C) Galactorrhea is fairly common up to old age. The discharge may vary in color from brown to milky. Hormonal causes are associ- ated with elevated prolactin levels or with pitu- itary or thyroid disorders. Tranquilizers have also been implicated. Simple abscesses do not cause galactorrhea.

Answer 287

24. (D) Fat necrosis is a rare condition that follows injury. Diagnosis may be difficult, and mam- mography and exicision may be necessary to rule out carcinoma. Sclerosing adenosis is a variant of fibrocystic disease and may present with a hard mass. In a hematoma, evidence of resolving ecchymosis may be present.

Answer 288

25. (D) Mammary fistula also known as Zuska’s disease is felt to represent dilated laciferous ducts, which develop chronic inflammation presenting with these periareolar draining sinuses. They will continue to recur until com- pletely excised, which may require removal of the terminal duct into the nipple, leaving the wound open.

Answer 289

26. (C) This entity is known as Mondor’s disease and is caused by superficial thrombophlebitis usually induced by surgery, infection, or trauma. The process is self-limiting and resolves within 2–10 weeks.

Answer 290

27. (A) Intraductal papilloma is the most common cause of bloody discharge from the nipple. The lesion is treated by excision and is benign in most cases. Cancer is present in 5% of cases. Preoperative ductography can be used to help locate the offending duct .

Answer 291

28. (D) Patients who present with fibrocystic mas- topathy at this age should undergo routine screening mammography, either regular film or digital, and ultrasound if no obvious benign etiology is seen on mammography. Spot com- pression mammography is done for any ques- tionable abnormality. Routine use of screening MRI is not indicated at this time.

Answer 292

29. (C) Coarse calicifications are usually benign. Fine, clustered califications are often milignant and require biopsy. Solid tumors of the breast, especially those that have increased in size or have changed in appearance, are suspicious for carcinoma and require biopsy.

Answer 293

30. (A) Any history of previous breast biopsy, even benign, does show an increase risk of breast cancer. Atypia, family history, and increasing age also increase a woman’s risk. Smoking has not shown an increase risk for breast cancer.

Answer 294

31. (D) ER and PR status should be determined in all cases of breast carcinoma. Positive ER and PR are indicative of an improved outlook and likelihood of response with antiestrogen med- ication. PR+ do not predict negative ER status.

Answer 295

32. (E) Recent studies are showing aromatase inhibitors to be more beneficial than tamoxifen in preventing breast cancer recurrence in post- menopausal women. Tamoxifen, raloxifene, and toremifene are all selective ER modulators (SERMS), which act by competitively blocking estrogen binding sites and thus reducing esto- gen stimulation of breast tissue. Megace (mege- strol acetate) has been used for metastatic breast cancer.

Answer 296

33. (C) The number of positive axillary nodes remains one of the best prognostic indicators in breast carcinoma. The current American Joint Committee on Cancer (AJCC) staging classifi- cation now defines patients with 1–3 positive nodes (N1), 4–9 positive nodes (N2), and 10 or more positive nodes (N3) due to their different prognosis.

Answer 297

34. (A) DCIS is a noninvasive lesion. Comedo DCIS is more aggressive than noncomedo DCIS. Axillary disease in uncommon is DCIS, and lymph node staging is generally not required. Breast conserving procedures can be performed as long as extensive or multicentric disease is not present. Radiation therapy is generally indicated after breast conserving therapy for DCIS.

Answer 298

35. (D) She is at increased risk for breast cancer and should be followed closely. LCIS is usually in incidental finding. Although multifocal through- out both breasts, it is thought not to be precan- cerous itself but rather an indicator of increased cancer risk. Therefore, wide resection is not indi- cated. Careful examinations, every 6 months and yearly mammograms are done to detect inva- sive carcinoma at the earliest time. Lifetime breast cancer risk is about 30%.

Answer 299

36. (C) The diagnosis should be made by nipple biopsy when suspected. Paget’s disease repre- sents a ductal carcinoma that has grown along the ducts into the nipple/areolar region. The lesion often presents with an eczematous rash, which does not resolve and can be diagnosed with a small incisional biopsy. Typically swollen vacuolated Paget’s cells are found on histolog- icl examination. Many cases involve small breast cancers, which are missed on clinical examination and mammogram. Surgical ther- apy is often curative. This is unrelated to Paget’s disease of the bone.

Answer 300

37. (A) Ipsilateral supraclavicular lymph node dis- ease is stage IIIC in breast cancer. The new AJCC staging system includes ipsilateral supr- aclavicular nodes as IIIC and not IV. These patients require appropriate metastatic workup and often get neoadjuvant chemotherapy.

Answer 301

38. (C) Both methylene blue or isosulfan (lymp- hazurin) blue dye can be used for sentinel lymph node identification and have been asso- ciated with some allergic reactions. Isosulfan blue has been associated with rare anaphylac- tic reactions in <1% of patients. Methylene blue can cause skin necrosis if injected too superfi- cially. Fluorenscein and indigo carmine are not given in these surgeries. 99 Tc is given for the lymphoscintigraphy and gamma probe isola- tion of the sentinel node and has no known anaphylactic reactions.

Answer 302

39. (D) Generally patients with small (<1 cm) breast cancers, which are pathologically node nega- tive, are spared from chemotherapy. Radiation and hormonal therapy is indicated. Partial breast irradiation can be offered though there is no current randomized data to show the best modality of treatment (currently an ongoing NSABP/RTOG trial).

Answer 303

40. (A) This patient has a palpable axillary lymph node making sentinel node biopsy contraindi- cated. The multicentricity of the disease also makes the use of sentinel lymph node biopsy relatively contraindicated. Radical mastectomies are no longer performed unless gross tumor invasion into the pectoralis muscle is found.

Answer 304

41. (E) Current National Institute of Health (NIH) consensus conference advises chemotherapy for all invasive cancers >1 cm as well as for node-positive cancers. Radiotherapy is required whenever breast conserving surgery is under- taken and tamoxifen should be given for all ER+ and/or PR+ invasive tumors whose patients are premenopausal.

Answer 305

42. (C) Breast cancer is the most common cancer during pregnancy. It is usually ER–/PR–. Patients can undergo chemotherapy (nonmethotrexate regimens) starting after the first trimester and continue on with the pregnancy. Radiotherapy cannot be given during pregnancy, so mastec- tomy is often indicated unless the patient is toward the end of the pregnancy, and the radio- therpy can be given postpartum.

Answer 306

43. (A) Axillary dissection during modified radical mastectomy requires exposing the long tho- racic and thoracodorsal nerves. Injury to the long thoracic nerve that supplies the serratus anterior muscle causes “winging of the scapula”. The intercostobrachial nerve supplies sensory innervation to the skin in the axilla and proxi- mal upper extremity. The medial and ulnar nerves are outside of the usually axillary dis- section field.

Answer 307

44. (B) Bone metastasis is the most common distant metastatic site for breast cancer. They are typi- cally osteolytic lesions and can be treated by biphosphonates, which inhibit bone deminer- alization and have been shown to reduce the pathologic fracture frequency and need of radiation.

Answer 308

45. (D) Follow-up after breast cancer treatment is very variable. There is no consensus and no follow-up test has shown a survival advantage. Routine 3–6 month clinical examinations and yearly mammography should always be per- formed. The use of tumor markers such as a CA 15-3 has not shown any proven significant value and may lead to unnecessary worry.

Answer 309

46. (E) There is no evidence that long-term insertion of breast implants leads to an increased inci- dence of breast cancer or detection of the cancer at an inappropriate late stage. Although the use of silicone gel implants is still confined by the Food and Drug Administration (FDA) to select circumstances (e.g., breast reconstruction fol- lowing mastectomy), retrospective studies to date have failed to demonstrate a significant increase in the incidence of collagen disease in patients who have had a silicone breast implant.

Answer 310

47. (A) Cancer of the breast in males constitutes <1% of total cases. It tends to present at a more advanced stage in men than in women, because it is often overlooked. It may easily be confused with the more commonly occurring condition of gynecomastia. Careful clinical radiological follow-up studies are indicated.

Answer 311

48. (D) In general, persistent gynecomastia should be evaluated to rule out endocrine abnormalities. In most cases, none are found. Subcutaneous astectomy is indicated if the patient is self- conscious.

Answer 312

49. (B) Cystosarcoma phyllodes is a tumor that is very slow growing and has a good prognosis if treated by mastectomy. It is characterized by large polygonal cells with abundant cytoplasm and lymphoid infiltration.

Answer 313

50. (D) Occult primary breast cancer is a rare but well-known entity. Stage for stage these patients have a similar prognosis as other patients with node-positive breast cancer. The primary tumor is often found in the breast (60–70% of mastec- tomy specimens). Either modified radical mas- tectomy and chemotherapy or just axillary dissection with radiation and chemotherapy are accepted treatment choices.

Answer 314

51. (B) Medullary tumors have an intense sur- rounding lymphoid reaction and though poorly differentiated, have a favorable prognosis com- pared to other invasive cancers. They tend to be hormone receptor negative.

Answer 315

52. (I) Paget’s disease is characterized by these large vacuolated intradermoid cells usually arising from a ductal carcinoma that is thought to have grown along the duct to the nipple.

Answer 316

53. (D) Inflammatory breast cancer is a very aggres- sive form of breast cancer characterized by intradermal lymphatic spread of tumor.

Answer 317

54. (F) Infiltrating lobular cancers have this typical linear (“indian-file”) arrangement of cells. There is a higher incidence of multifocality and bilat- erality with lobular cancers. These cancers have a greater tendency to be hormone sensitive.

Breast Flashcards

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